Bioethics at Midlife

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The resident is seated at the conference table giving her colleagues an overview of a patient in one of Stanford Hospital’s ICUs. The unconscious man with no ID had been brought in the previous day after being found in a pool of blood. He had vomited an additional 5 liters of blood and his condition remained unstable. If he begins to bleed again, the resident says, the medical team feels there’s little more that can be done.

Next to her at the table is David Magnus, director of Stanford’s Center for Biomedical Ethics and a regular participant in the weekly ICU interdisciplinary rounds, along with physicians, social workers, nurses, respiratory therapists, dietitians and clergy. At these sessions, the participants review the status of all the patients currently in the medical ICU. “Who is making the decision to discontinue medical care?” Magnus asks the resident.

“Well,” she replies, “we are.”

“You can’t do that,” Magnus points out, explaining that for an unresponsive patient with no designated representative to make a decision, an ethics consult is required. The ethics team would assess the situation and make a recommendation to the hospital’s chief of staff, who would then make the decision. “So, are you requesting an ethics consult?” Magnus asks with a gentle smile. The resident assents, and Magnus writes himself a note to follow up on this case.

A clinical ethics consult — which addresses situations such as how to protect a patient from the harmful acts of a family member or whether a psychiatric patient can refuse treatment — allows a small, multidisciplinary team to gather relevant facts from all of the involved parties, elucidate values and make recommendations in which those values are prioritized. In emotionally wrought circumstances when there may be conflicts between the desires of the patient, the patient’s family and the doctors and nurses providing care, the ethics team works to provide thoughtful, respectful and evidence-based guidance. The team approach is a stark contrast to the early days of medicine when doctors alone made the decisions, often without consulting the patient.

No longer relegated to the background, bioethics has become a strong team player in the medical establishment as society wrestles with such high-profile issues as the role of stem cell research and how to handle end-of-life care. And in these situations, bioethicists wear many hats. They give scientists and clinicians practical tools and advice for dealing with the ethical, legal and social ramifications of their work. They also play roles in educating the public, protecting the rights of patients and giving a voice to vulnerable populations.

“The world of medicine has been washed up in this tsunami of commercial health care, and it makes it very difficult to see each patient as a person,” says Albert Jonsen, PhD, one of the early bioethicists and author of The Birth of Bioethics, among other books. “That’s what bioethics is supposed to do.”

Bioethics’ reach extends far beyond the bedside and the practice of clinical ethics. Its primary purpose is to inquire, reflect and debate the ethical issues associated with medicine, bioscience and health. Somewhere between 2,000 and 6,000 people in the United States focus on bioethics as their primary area of research, teaching or clinical practice, says Magnus. Their debates play out in a variety of venues, from the courts, to the halls of government, to the media.